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New Patient - Acupuncture & Chinese Herbal Medicine Information Form
Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All answers are confidential.
If someone referred you to us, whom specifically may we thank?
What symptoms/conditions bring you in today?
Other problems/concerns to be addressed:
How long have you had this condition?
Have you experienced this before? YES NO
What seemed to be the initial cause?
What seems to make it better?
What seems to make it worse?
Does it bother your: Sleep Work Other:
FAMILY HISTORY - Complete for each family member, indicating any of the illnesses that they have ever had. Check in the appropriate box(es).
Date of last physical examination:
Name & Address of physician:
Phone number of physician:
*Do I have the permission to contact your physician to further serve you with your health and wellness?
*Have you ever been treated with acupuncture &/ or Chinese herbal medicine before?
GYNECOLOGY (Women please answer)
Age of first menses: Date of last menstrual period:
Duration of flow:
Blood clots: Yes No When:
Length of cycle:
Color of menstrual blood: pale bright red dark red brown other:
Texture of menstrual blood: thick thin watery normal
Pain: Yes No When:
Irregular periods (describe):
PMS (please describe):
Current method of contraception:
Past method of contraception:
Are you currently pregnant? Yes No
Number of pregnancies:
Number of live births:
Number of miscarriages:
Number of abortions:
Any premature births:
Breast (lumps, cysts, tenderness, etc.):
Urinary tract infections: How frequent?
Vaginal infections/ discharges (describe color):
Pain/itching of genitalia:
Pap smear: normal abnormal
Date of last Pap smear:
Menopause (date of onset):
Any bleeding since?
Are you currently on Hormone Replacement Therapy (HRT)? Yes No
How long have you been on HRT?
Any side effects?
Please check "C" if the condition is current or "P" is you had it in the past:
Pain and Tenderness = O
Numbness and Tingling = Z
Swelling and Stiffness = X
(draw your signature)